Influence of Imaging on the Negative Appendectomy Rate in Pregnancy

Appendectomy is the most common non-gynecologic surgery performed during pregnancy. Little data exist on the accuracy of imaging studies in the diagnosis of appendicitis in pregnancy. The objective of this study was to evaluate the probability of ultrasound and computed tomography (CT) scan in diagnosing appendicitis in pregnancy, as reflected in the negative appendectomy rate. We retrospectively reviewed the charts of 86 pregnant women who underwent an appendectomy between January 1, 1997 and January 1, 2006. Patients were divided into three groups: clinical evaluation, ultrasound, and ultrasound followed by a CT scan. The clinical evaluation group had 13 patients, with a negative appendectomy rate of 54% (7/13). Fifty-five patients underwent an ultrasound alone, with a negative appendectomy rate 36% (20/55). In the ultrasound/CT group (n = 13), the negative appendectomy rate was 8% (1/13). There was a significant reduction in the negative appendectomy rate in the ultrasound/CT scan group compared to clinical evaluation group (54 vs 8%, p < 0.05). This reduction was not achieved in the ultrasound group when compared to the clinical evaluation group or the ultrasound/CT group (p = 0.05). A significant reduction was achieved when the ultrasound/CT group was compared to the patients in the ultrasound only group who had a normal or inconclusive ultrasound (p < 0.05). Our data documents a very high negative appendectomy rate in the pregnant patient. We recommend an ultrasound followed by a CT scan in patients with a normal or inconclusive ultrasound.     

Differences in morphology and contractility of the bulbospongiosus and pubococcygeus muscles in nulliparous and multiparous rabbits

In women, birth trauma can result in altered anatomy of supporting structures of the pelvic floor and in the development of urinary incontinence. The goal of this study was to investigate the association between parturition and the morphology and function of perineal and pelvic muscles in the female rabbit. In ten nulliparous and ten multiparous same-age females, we investigated morphological, histological (n = 5 females/group), and contractile characteristics (n = 5 females/group) of the perineal bulbospongiosus (Bsm) and the pelvic pubococcygeus (Pcm) muscles. Bsm and Pcm muscles of multiparous females were significantly lighter, they had a smaller cross-sectional fiber area, and developed significantly lower twitch and tetanic tension force in response to electrical stimulation than muscles of nulliparous females. In female rabbits, multiparity is associated with potentially pathological changes in the morphological and functional characteristics of these perineal and pelvic muscles, possibly as a result of stretching during parturition.     

Intraoperative assessment of femoral component rotational alignment in total knee arthroplasty

Poor clinical results following total knee arthroplasty like flexion gap instability or anterior knee pain may be related to femoral component rotational malalignment. The transepicondylar axis has been recommended as a landmark to consistently recreate a balanced flexion gap. However, the reproducibility to identify the transepicondylar axis intraoperatively is low. In this feasibility study we wanted to find out whether fluoroscopy-based CT scans obtained by a motorized mobile C-arm (Iso C 3D) may be useful to asses the transepicondylar axis intraoperatively. Following the femoral resections the Iso C 3D was used intraoperatively in ten knees with mild to severe deformities. On multiplanar reconstructions of the distal femur the clinical epicondylar axis as well as the angle to the posterior cut (condylar twist angle) could be easily measured. The scanning time was 40 s and the extra time needed for the whole setup about five to ten minutes. The Iso C 3D was helpful to intraoperatively identify the transepicondylar axis and the condylar twist angle, especially in cases with severe deformity or dysplasia when standard landmarks are difficult to determine. Florian Geiger and Dominik Parsch contributed equally to this article.     

Tracheal chondrosarcoma

Tracheal chondrosarcomas are rare, with only 14 cases previously documented. We report a case of chondrosarcoma of the trachea and review other published cases. Our patient was a 34-year-old man who began to feel shortness of breath 8 months after initial hemoptysis. Transverse and coronal computed tomography demonstrated a tumor that was obstructing nearly 80% of the tracheal lumen at the thoracic inlet. A bronchoscopic biopsy specimen led to an initial diagnosis of chondroma. Five tracheal rings from the third to the seventh including the tumor were completely resected, and an end-to-end anastomosis was performed. The histological diagnosis of the surgical specimen showed it to be a chondrosarcoma. The patient was alive without recurrence at 6 years 4 months after surgery. Because recurrence after incomplete resection and malignant transformation can occur with chondromas, radical resection of the trachea is recommended for all cartilaginous tumors of the trachea.     

Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident’s training

Background In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training. Methods A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005. Results The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates. Conclusions Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.     

Does stone dimension affect the effectiveness of ureteroscopic lithotripsy in distal ureteral stones?

Objective To investigate whether stone dimension is a restrictive factor for ureterorenoscopic procedures. Materials and methods A group of 416 patients who had undergone ureterorenoscopic pneumatic lithotripsy (URS-PL) for lower ureteral stones between January 1999 and June 2006 in our clinic had been evaluated retrospectively. Two hundred and seventy (270, 64.9%) patients were men and 146 (35.1%) were women. The mean age of the patients was 36.61 (±12.43) years. Patients were grouped according to stone dimension; 193 patients with stones smaller than 1 cm being group 1 and 223 patients with stones ≥1 cm in dimension being group 2. Stone-free rate, operative time and rate of complications of the groups were compared. Pearson’s correlation test, χ² test, Fischer’s exact test and Student’s t-test were used for the statistical analysis. The p value was accepted as being meaningful if p < 0.05. Results For group 1, the mean operative time was 39.19 (±18.33) min. Proximal stone migration in five and false passage formation in three patients was observed. Three patients were stone-free after a second session of URS-PL. The cumulative stone-free rate was 97.4% (188/193). For group 2, the mean operative time was 48.5 (±11.31) min. About 208 (93.27%) patients were stone-free after the first session and an additional eight patients became stone-free after the second session of URS-PL. False passage, ureteral perforation, ureteral avulsion and stricture were observed in four, six, one and one patients, respectively. No proximal stone migration was observed. The cumulative stone-free rate was 96.86% (216/223). Conclusions The effectiveness of ureterorenoscopy (URS) in the treatment of distal ureteral stones was independent of stone dimension. However, the operative time was longer and the rate of perforation was higher in stones with a diameter ≥1 cm. On the other hand, the migration rate was higher in stones <1 cm in diameter. Generally speaking, there was no meaningful effect of stone dimension on complication rates.     

Treatment of Hemorrhoids in Day Surgery: Stapled Hemorrhoidopexy vs Milligan–Morgan Hemorrhoidectomy

Background Recently, it has been demonstrated that surgical treatment of hemorrhoids in a day-care basis is possible and safe. The aim of this study was to compare the Longo stapled hemorrhoidopexy (SH) and the Milligan–Morgan hemorrhoidectomy (MMH). Methods One hundred seventy one patients (95 cases in SH group and 76 cases in MMH group) entered the study: 83 cases were III degree hemorrhoids, 88 IV degree. A priori and a post hoc power analysis were performed. Results, prospectively collected, were compared using chi squared test and student t test. Visual analog scale was used for pain evaluation. Postoperative pain, duration of pain, wound secretion, bleeding, resumption of a normal lifestyle, and postoperative complication were evaluated. Results Surgical time was 28.41 ± 10.78 for MMH and 28.30 ± 13.28 min in SH (P = 0.94). Postoperative pain was not different between MMH and SH during the first two postoperative days (4.73 ± 2.91 vs 5.1 ± 3.048; P = 0.4), during the following 6 days, patients treated with SH had less pain (4.63 ± 2.04 in MMH vs 3.60 ± 2.35 in SH; P = 0.006). In the SH group, seven patients needed further hospital stay for complicated course. SH showed higher incidence of anal fissure compared with MMH (6.3% vs 0%; P = 0.025) but no differences in urinary retention, anal stricture, urgency, or anal hemorrhage. Conclusions This study confirms that SH is associated with less postoperative pain and shorter postoperative symptoms, compared with MMH. SH may be a viable addition to the therapy for hemorrhoids with some advantages in early postoperative pain and some disadvantages in postoperative complications and costs.     

Cecal volvulus in cerebral palsy: Report of a case

A rare case of cecal volvulus in cerebral palsy that was preoperatively diagnosed and surgically treated without complications is herein reported. A 45-year old man, who had been treated for cerebral palsy as a result of a neonatal cerebral hemorrhage, was admitted to our hospital because of abdominal pain and vomiting. A plain abdominal X-ray film showed evidence of a huge quantity of gas in the left abdomen. Using a gastrographin enema from the colonoscope, an obstruction of the ascending colon was revealed with tapering of the lumen. A computed tomography scan showed a grossly dilated air-distended bowel in the left abdomen and soft tissue with internal architecture containing swirling strands of soft tissue and fat attenuation. An emergency laparotomy was performed. During the laparotomy the ileocecal region, which was unfixed at the retroperitoneum, was found to be twisted counterclockwise by 360° around the mesentery with the terminal ileum, thus resulting in a diagnosis of cecal volvulus. We therefore conducted an ileocecal resection. Cecal volvulus is an uncommon form of intestinal obstruction with a high mortality rate and may present considerable difficulty in diagnosis. Although cecal volvulus is rare as a cause of intestinal obstruction, it should be included in the differential diagnosis of bowel obstruction in cerebral palsy.     

Papillary Thyroid Carcinoma: Factors Influencing Recurrence and Survival

Background The prognosis of patients with papillary thyroid carcinoma (PTC) is usually favorable; however, a subset of patients can develop local recurrence or distant metastases. The aim of this study was to evaluate the prognostic factors influencing the recurrence and the survival rate in 950 PTC patients. Materials and Methods From 1990 to 2005, 950 consecutive patients affected by PTC were operated on at our Department. We analyzed the prognostic role of the following parameters: gender, age at initial treatment, extent of thyroid surgery, node dissection, tumor size, node metastases, distant metastases, stage, and 131-I therapy. Results Seventy-nine patients (8.3%) developed locoregional or distant metastases after an average follow-up of 7.8 years (range 2–17 years); in particular local recurrence was observed in 25 cases and distant metastases in 54 cases. The global 10- and 15-year survival rates were 91.38% and 88.69%, respectively. At univariate analysis, all variables were significantly correlated with recurrence (P = .001) except gender (P = .3); moreover, gender (P = .2), node dissection (P = .5), and node metastases (P = .06) were not significant on 10- and 15-year survival. At multivariate analysis the age at first treatment, T4, M+, stage IV, the extent of thyroid surgery, and the 131-I therapy resulted to be significant and independent prognostic factors (P < .001). Conclusion Our data, in disagreement with other staging systems, suggest that gender does not play a significant role both in recurrence and survival. Moreover, the 131-I therapy was a statistically significant prognostic factor at univariate and multivariate analyses.